Prevalence and factors associated with hepatitis B and C virus infections among female Sex workers in Ethiopia: Results of the national biobehavioral Survey, 2020

Background Hepatitis B and C virus infections are endemic diseases in sub-Saharan Africa, the region with the highest prevalence of these infections in the world. Female sex workers are exposed to sexually transmitted infections, including hepatitis B and C, because of their high-risk sexual behavior and limited access to health services. There are no large-scale data on the prevalence of hepatitis B and C virus infections among female sex workers in Ethiopia, a critical gap in information this study aimed to fill. Methods This was a cross-sectional, biobehavioral survey conducted from December 2019—April 2020 among 6085 female sex workers aged ≥15 years and residing in sixteen (16) regional capital cities and selected major towns of Ethiopia. Blood samples were collected from the participants for hepatitis B and C virus serological testing. The data were collected using an open data kits (ODK) software and imported into STATA version16 for analysis. Descriptive statistics (frequencies and proportions) were used to summarize data on the study variables. Bivariable and multivariable logistic regression analyses were conducted to determine the strength of association between independent variables (risk factors) and the outcome (hepatitis B and C virus infection). Adjusted Odd ratio (AOR) was used to determine independent associations, 95% confidence interval to assess precision of the estimates, and a P value ≤ 0.05 to determine statistically significant. Results The prevalence of hepatitis B and C infections among the 6085 female sex workers was 2.6% [(95% CI (2.2,2.8)] and 0.5% [(95% CI (0.4,0.7)], respectively. Female sex workers who had 61–90 and ≥91 paying clients in the past six months [(AOR = 1.66; 95% CI, (0.99, 2.79); P = 0.054] and [(AOR = 1.66 95% CI, (1.11, 2.49); P = 0.013], respectively, age at first sex selling of 20–24 and >25 years [(AOR = 1.67; 95% CI, (1.14, 2.44); P = 0.009)] and [(AOR = 1.56; 95% CI (1.004, 2.43); P = 0.048)], respectively, known HIV positive status [(AOR = 1.64; 95% CI (1.03, 2.62); P = 0.036] were significantly associated with the prevalence of hepatitis B virus infection. Similarly, hepatitis C was significantly associated with, age at first sex ≤15 years and age 16–20 years [(AOR = 0.21; 95%CI (0.07,0.61); P = 0.005)] and [(AOR = 0.18; 95% CI (0.061, 0.53); P = 0.002)], respectively, known HIV positive status [(AOR = 2.85; 95%CI (1.10,7.37); P = 0.031)] and testing positive for syphilis [(AOR = 4.38; 95% CI (1.73,11.11); P = 0.002)], respectively. Conclusion This analysis reveals an intermediate prevalence of hepatitis B and a low prevalence of hepatitis C infection among female sex workers in Ethiopia. It also suggests that population groups like female sex workers are highly vulnerable to hepatitis B, hepatitis C, and other sexually transmitted infections. There is a need for strengthening treatment and prevention interventions, including immunization services for hepatitis B vaccination, increasing HCV testing, and provision of treatment services.

rural settings, where the female are twice more affected than males (12).

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Ethiopia is in the region where HBV prevalence is considered hyper-endemic with a prevalence of 94 between 8%-12%, and that of HCV prevalence is estimated at not less than 2.5% (13 including HBV and HCV, and should perceive priority in the national HIV/AIDS program (18).

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Although there is an ongoing HBV, HCV, and other STI program in the country, there is no 104 national data among FSW to determined HBV and HCV prevalence and driving factors. Therefore, 105 the current study was conducted to explore the prevalence of HBV and HCV infections and 106 identify the factors associated with these infections among FSW in Ethiopia.

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Study setting and population: 109 The study was done in Ethiopia, a country divided into eleven regions and two city administrations,  This was a crass-sectional, nation-wide, biobehavioral study conducted among FSW aged 122 ≥15 years during the period from December 2019 -April 2020.

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Target population: 124 The target population of the study is all FSW living in cities and towns in Ethiopia, and the 125 sampling frame is the list of FSW residing in the regional capitals and selected towns with FSW-126 hotspots in Ethiopia.

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Study population: 128 FSW aged ≥15 years residing in regional capitals and selected towns with FSW-hotspot or who 129 worked in these cities and towns in the last one month preceding the survey. The survey included 130 both fixed (venue-based) and floating (street-based) FSW.

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Inclusion and exclusion criteria: 132 We included women aged ≥15 years, who received money/other benefits in exchange for sex with 133 four or more people within the last 30 days, agree to participate in the survey including 134 interviewing and biological testing, able to provide informed consent and communicate in one of 135 the survey languages, had a valid coupon provided by the study team , and residing or working in 136 the survey city or town for the last one month.

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The information of Ethiopia background should be summarized and focus on settings where the study have been conducted. cross 1. How towns and cities were selected? 2. There are no FSW in rural settings? 3. It is not national representative study because some areas were excluded.

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Sample size and sampling procedure: 138 The sample size was determined by single population proportion formula with sample 450-900, and 12 seeds for each site with sample of 1101 were recruited. The "seeds" 153 were selected based on the type of sex worker, age category, and geographic location of the site.

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These include those FSW who were bar-and/or hotel-based, red lighthouses, local drinking 155 houses, street-based and hidden (cell phone-based).

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FSW with a known social network were given each three coupons for use to invite her friends or 157 other FSW contacts who were in her network. This approach helped in reaching as many eligible 158 FSW as possible. The coupon remained active from the day it was given to the potential participant The formula is not needed in manuscript writing. Better to delete it What is needed is not the calculation of cities rather the calculation of the size of participants (FSWs         previous study also indicated that HCV sero-reactivity or positivity was significantly predicted 419 and associated with syphilis sero-reactivity or positivity (63). Moreover, a study conducted by 420 Tessema B, et al (50) suggested that the highest rate of co-infection and the statistically significant 421 relationship between HCV and syphilis infections might be due to the fact that these pathogens 422 share common modes of transmission and risk groups. These findings are in line with our finding 423 showing that FSW with HCV infection were 4.4 times more likely to be syphilis sero-reactive or 424 positive than those who were syphilis non-reactive or negative. As HCV positive FSW were at a 425 higher risk for having syphilis, prevention mechanisms and intervention need to be instituted 426 among FSW to decrease further transmission of HCV and syphilis to the general population.

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Of 6085 participants included in our study,184 (3%) had results for both HBsAg and HCVAb. The

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The previous prevalence estimates of HBV among general population in Ethiopia ranged from 434 8%-12%, and HCV prevalence estimated at greater than 2.5% (13). These findings were higher